Menopause, depression, cancer and chronic pain can make a woman’s sex life difficult. Here’s how to regain intimacy, desire and confidence.

But when desire wanes, when the body changes or when aspects of sex become painful, women can develop psychosexual distress and dysfunction that affect them well beyond the bedroom.

To make an appointment at the OHSU Center for Women’s Health, call 503-418-4500.

Fortunately, the OHSU Center for Women’s Health – the only clinic of its kind on the West Coast – specializes in vulvovaginal health and sexual well-being, employing a collaborative team of clinicians trained to help patients experiencing difficult scenarios like pregnancy, menopause, cancer and trauma.

Sex and pregnancy

One of the biggest barriers to sex during pregnancy is fear that penetrative intercourse will either hurt the baby or induce labor. But according to Dr. Leo Han, an OB-GYN and assistant professor in OHSU’s Obstetrics and Gynecology Department, your baby will be perfectly safe.

“The best studies we have do not show any sign that having intercourse increases your risk of either miscarriage or early delivery,” he said.

So aside from some creative positioning to make room for that baby bump, couples should feel totally safe having intercourse.

Things can get a little more complicated post-delivery, however. Perineal lacerations can be painful, especially if the tear requires sutures; at that point, Dr. Han recommends refraining from intercourse for approximately six weeks.

Low desire and postpartum blues are also common. And then there’s breastfeeding, which causes a low-estrogen state; according to Dr. Han, this is the body’s natural way of keeping itself from getting pregnant again too soon, but it can also create vaginal dryness and discomfort during intercourse.

Dr. Han reminds patients’ partners that they need to be respectful of postpartum mental health, too.

“Pregnancy is just the condition,” Dr. Han said. “But the things that come up – low arousability, low desire, pain and discomfort – treatments for those have always been communication with your partner and being able to increase sexual contact in ways that are comfortable and safe.”

Sex and cancer

Treatments like chemotherapy, radiation and surgery can affect your sex life in unanticipated ways. According to OHSU gynecologic oncologist Dr. Melissa Moffitt, the struggle with sex for cancer patients is multifaceted and dependent on the type of cancer: vulvovaginal surgeries can result in pain or difficulty with vaginal penetration; hormonal changes brought on by certain treatments can make estrogen levels plummet (which kills libido); and there’s the emotional trauma caused by battling a life-threatening illness, all of which places enormous stress on sexual function.

“It can threaten your relationship,” she said. “You want to feel ‘normal’ again, and that can be challenging; a lot of our patients don’t have vaginas or clitorises, so we have to talk about different forms of intimacy as a new expression of sexuality.”

Another part of reclaiming your sexuality after cancer involves emotional support.

“I think when you’ve been through a life-threatening trauma – it doesn’t matter what kind it was – if your brain doesn’t think you’re safe, why would sexual desire be there?” said physician assistant Lisa Egan.

“So much of sex is goal-oriented,” said Egan. “There’s what it’s supposed to look like and how it’s supposed to end. Learning how to do intimate sexual touch that doesn’t involve intercourse – how to have intimate connection – can be really powerful.”

Sex and menopause

An adamant advocate for sex after 51 (the average age that Americans start menopause), Dr. Adams explains that menopause’s estrogen dip can lead to low libido and vaginal tenderness.

“The vagina is a little more fragile, a little drier, a little more sensitive,” she said. “And it goes along with decreased lubrication, discomfort or pain with intercourse, bleeding or spotting – and decreased arousal, orgasm and desire.”

While all that sounds terribly daunting, the silver lining is that it’s all treatable.

“You do not have to accept pain as part of menopause; topical estrogen can make a big difference,” she said. “Even women who’ve had estrogen-sensitive cancers can use topical estrogen because it doesn’t increase the risk of recurrence.”

The answer to your vaginal woes may also lie in your pantry; natural oils like coconut oil make cheap, effective lubricants. If low libido is an issue, Dr. Adams examines her patients’ physical, mental and relationship health – all factors for a satisfying sex life – and often recommends they spice things up by exploring local sex shops like She Bop.

“Sex is supposed to be fun – it’s supposed to be adult play,” she said. “I think it’s hugely important for your quality of life.”

Sex and pain

It’s disheartening when something that’s supposed to feel good doesn’t. Pain during intercourse can strip the act of its benefits and, if left unchecked, can generate feelings of fear, avoidance, depression and self-loathing. Sexual pain is rarely dealt with during medical exams, but it can be triggered by numerous conditions, such as menopause, pelvic cancers, chronic yeast infections and provoked localized vulvodynia (PLV), a vulvar disorder that causes mild to excruciating pain upon vaginal penetration.

According to Dr. Catherine Leclair, director of OHSU’s Vulvar Health Program, about 40 percent of her patients suffer from PLV, and 10 to 15 percent of women will experience it in their lifetime. The condition was largely misunderstood for decades, and the treatment advice patients received ran the gamut from mildly unhelpful (use more lube) to ludicrously ignorant (have more frequent intercourse to keep the vagina stretched out).

Researchers still haven’t pinpointed an exact cause, but they do have clues.

“What we do understand is the nerves [at the vaginal opening] are proliferated to the point where there’s a lot of them and they’re large,” said Dr. Leclair. “They create this tangled network, and within that are trapped inflammation cells.”

Dr. Leclair says people with PLV and sexual pain are more prone to depression and anxiety, often clinging to fatalistic views of their romantic or sexual lives.

“If something that’s supposed to be fun and feel good is actually the opposite, it pushes you away from a partner – you feel at fault and embarrassed,” she said. “Women feel isolated and lonely because they have this belief that everybody out there’s having comfortable, easy sex whenever they want.”

It gets especially stressful if partners either assume the same, or view sexual avoidance as a sign of nonattraction, which can create a cycle of resentment and guilt.

As such, healing sexual pain requires tending to the mind and body simultaneously. Treatment includes any combination of physical therapy, topical ointments, surgery, group therapy, couple’s counseling and working with a licensed sex therapist specializing in psychosexual distress.

“It’s never normal for women to have pain with sexual activity,” said Dr. Leclair. “If you are having pain with sexual activity, you deserve to get help – it’s a difficult process that most women can’t do alone.”

“One of the hallmark symptoms of clinical depression is a chemical change where we are unable to enjoy things we used to enjoy, called anhedonia,” she said. “The desire to have sex is gone, but the ability to feel arousal or pleasure during sexual activity is also decreased – and most of the medicines we use to treat depression and anxiety can cause sexual dysfunction, so it gets complicated.”

Whether the depressed mental state stems from abuse and trauma, illness or neurological chemical imbalance, the repercussions are similar.

“One of the most common things we see is how it affects relationship – the ability to be intimate with a partner,” said Dr. Cirino.

This can be especially true for sexual abuse victims with symptoms of PTSD, where intimate touch may trigger fear instead of arousal. And while the Me Too movement has paved the way for legitimizing women’s suffering at the hands of sexual predators, it’s still the victims who are often saddled with debilitating trauma and sexual dysfunction.

Sex and healing

While these unsexy scenarios range from mildly inconvenient to horribly complex, the key commonalities to healing are similar: diagnosis, communication and patience. Find a provider familiar with sexual dysfunction, and talk to them if you’re experiencing sexual pain or low libido, or are struggling with arousal and orgasm.

“This is something that can get better,” Egan said. “This is not your new normal.”

If you have a partner, communicate your experience honestly, and involve them in the recovery process – Egan adds that miscommunication will often trigger breakups in otherwise healthy relationships. “

We see a lot of partners who are so supportive, but they don’t know how to help,” she said.

Finally, be patient with yourself. Overcoming sexual dysfunction is a multifaceted process regardless of its cause, and one where women historically haven’t had much legitimate support. (There are only two FDA-approved treatments for female sexual dysfunction, and more than 35 for men.) But clinicians want women to know that help is out there, that they’re not alone and that they deserve a thriving sex life.

“There are so many things that happen to us just because we’re women,” said Dr. Adams. “It’s really important that we claim our sexuality, not as being viewed by a man or a partner, but instead claim it for ourselves, accessing the help that’s available and creating support for each other. Our sexual life is for us.”

This article was written by Maya Seaman with illustrations by Audrey Lee, and it originally appeared in the Portland Monthly 2018 Women’s Health Annual magazine.

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